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While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention?
- A. Respiratory rate of 42
- B. Lethargy for the past hour
- C. Apical pulse of 54
- D. Coughing up copious secretions
Correct Answer: A
Rationale: Respiratory rate of 42. An elevated respiratory rate indicates potential airway obstruction, requiring urgent intervention.
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The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.
The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as the cause of the findings?
- A. Decreased cardiac output
- B. Tissue hypoxia
- C. Cerebral edema
- D. Reduced oxygen saturation
Correct Answer: B
Rationale: Tissue hypoxia. Iron deficiency anemia reduces oxygen-carrying capacity, causing tissue hypoxia.
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
- A. Repeat glycohemoglobin in 24 hours
- B. Document Accu-checks, intake and output every 4 hours
- C. Humulin N 20 units IV push
- D. IV fluids of 0.9% normal saline at 125 ml per hour
Correct Answer: C
Rationale: Regular insulin is the only insulin that can be given by the intravenous route. Humulin N is not suitable for IV administration, making this the priority order to question.
An adult asks the nurse what could be causing him to have a black tongue and black stools. The following items are in the client's history. Which is most likely to be causing his symptoms?
- A. He is taking bismuth subsalicylate (Pepto-Bismol) for loose stools.
- B. He has been eating a lot of beets and broccoli recently.
- C. He has been taking iron tablets for anemia.
- D. He eats a lot of red meat.
Correct Answer: A
Rationale: Bismuth subsalicylate commonly causes black tongue and stools, a harmless side effect, unlike the other options.